April 19  2015, Sunday
When should aspirin be stopped before non cardiac surgery?
Dr KK AggarwalFor patients who are on aspirin for primary or secondary prevention of cardiovascular disease, aspirin should be stopped seven days before noncardiovascular surgery.

The best evidence regarding the impact of aspirin on outcomes comes from the POISE–2 trial in which 10,010 patients scheduled for noncardiac surgery, with or at risk of atherosclerotic disease, were randomly assigned to either aspirin or placebo.

The primary outcome of death or nonfatal heart attack at 30 days was similar in both groups as well as between those who were taking long–term aspirin and those who were not. As expected, major bleeding was more common in the aspirin group.

Based on POISE–2, the recommendation is to stop aspirin about seven days before noncardiovascular surgery.
213th Meeting of the Central Working Committee of Indian Medical Association at Hotel Radisson Blu, New Delhi.
  • In cases of breech presentation, planned cesarean delivery is associated with fewer adverse outcomes than vaginal delivery or cesarean delivery during labor, reported a new study published online in Obstetrics & Gynecology.
  • More than half of Medicare beneficiaries undergoing cataract surgery undergo at least one preoperative test, despite robust evidence showing that preoperative tests are not associated with any improvement in outcomes, suggests new research published online April 15 in the New England Journal of Medicine.
  • The beneficial effects of subthalamic nucleus deep brain stimulation on pain in patients with Parkinson's disease persist long-term, suggests a new study published online in JAMA Neurology.
  • New research suggests that women with doctor-diagnosed celiac disease are more likely to miscarry or deliver preterm than women with no history of the condition. The findings are published online April 15 in Annals of Gastroenterology.
  • Depression and diabetes each independently raise the risk of developing dementia, and having both conditions poses the greatest risk, especially in those younger than 65 years, reported a Danish population-based study published recently in JAMA Psychiatry.
Dr KK Spiritual Blog
What is the importance of silence?

True silence is the silence between thoughts and represents the true self, consciousness or the soul. It is a web of energized information ready to take all provided there is a right intent. Meditation is the process of achieving this silence.

Observing silence is another way of getting benefits of meditation. Many yogis in the past have recommended and observed silence now and then. Mahatma Gandhi used to spend one day of each week in silence. He believed that abstaining from speech brought him inner peace and happiness. On these days, he communicated with others only by writing on paper.

Hindu principles also talks about a correlation between mauna (silence) and shanti (harmony). Mauna Ekadashi is a ritual followed traditionally in our country. On this day the person is not supposed to speak at all and instead observe complete silence throughout day and night. It gives immense peace to the mind and strength to the body. In Jainism, this ritual has a lot of importance. Nimith was a great saint in Jainism who long ago asked all Jains to observe this vrata. Some people recommend that on every ekadashi one should observe silence for few hours in a day, if not the whole day.

Deepak Chopra in his book ‘The Seven Laws of Spiritual Success’ talks in great detail about the importance of observing silence in day to day life. He recommends that everyone should observe silence for 20 minutes everyday. Silence helps to redirect our imagination towards self from the outer atmosphere. Even Swami Sivananda in his teachings recommends daily observation of mauna for 2 hours during ekadashi, take milk and fruits every day, study one chapter of Bhagwad Gita daily, do regular charity and donate one-tenth of the income in the welfare of the society.

Ekadashi is the 11th day of Hindu lunar fortnight. Ekadashi is the day of celebration occurring twice a month, meant for meditation and increasing soul consciousness. Vinoba Bhave was a great sage of our country who is known for this bhoodaan movement. He was a great advocator and practical preacher of mauna vrata.

Mauna means silence and vrata means vow; hence, mauna vrata means vow of silence. Mauna was practiced by saints to end enmity and recoup their enmity. Prolonged silence as the form of silence is observed by the rishi munis involved for prolonged periods of silence. Silence is a source of all that exists. Silence is where conscious dwells. There is no religious tradition, which does not talk about silence. It breaks outward communication and forces a dialogue towards inner communication. This is one reason why all prayers, meditation and worship or any other practice whether we attune our mind to the spiritual consciousness within are done in silence. After the death of a person it is a practice to observe silence for two minutes. The immediate benefit is that it saves a tremendous amount of energy.

Silence is cessation of both sensory and mental activity. It is like having a still mind and listening to the inner mind. Behind this screen of our internal dialogue is the silence of spirit. Meditation is the combination of observing silence and the art of observation.
Cardiology eMedinewS
  • Heritable factors appear to contribute to the risk for cardiac arrest in patients receiving dialysis, suggests a study published online April 16 in the Journal of the American Society of Nephrology.
  • Functionally limited heart-failure patients who received a left ventricular assist device (LVAD) as destination therapy had significantly improved survival and functional status at 12 months when compared with similar patients treated with optimal medical therapy alone; however, there was an increased risk of adverse events with LVAD therapy. These findings were presented at the International Society for Heart and Lung Transplantation 2015 Scientific Sessions (ISHLT).
Pediatrics eMedinewS
  • For children who do not have any known risk factors for cancer, growth hormone therapy does not increase future risk of developing a malignancy, suggested a recent clinical review published online in the Journal of Clinical Endocrinology & Metabolism.
  • Measuring neural activity in language-sensitive brain regions of toddlers with autism spectrum disorder may assist in the identification of those who go on to have poor language outcomes, suggests a new study published online in Neuron.
Make Sure
Situation: A patient with acid peptic disease was denied any painkiller for his distressing illness.
Reaction: Oh, my God! Why did you not give him nimesulide?
Lesson: Make sure to prescribe nimesulide as it is safe in acid peptic disease.
Dr Good Dr Bad
Situation: A patient with erectile dysfunction came with chest pain.
Dr Bad: Its non cardiac.
Dr Good: This pain can be cardiac in origin.
Lesson: Men who present with erectile dysfunction may be at higher risk for subsequent development of cardiovascular events.

(Copyright IJCP)
Inspirational Story
It’s All Good

I heard the story told recently about a king in Africa who had a close friend that he grew up with. The friend had a habit of looking at every situation that ever occurred in his life (positive or negative) and remarking, "This is good!"

One day the king and his friend were out on a hunting expedition. The friend would load and prepare the guns for the king. The friend had apparently done something wrong in preparing one of the guns, for after taking the gun from his friend, the king fired it and his thumb was blown off. Examining the situation the friend remarked as usual, "This is good!" To which the king replied, "No, this is NOT good!" and proceeded to send his friend to jail.

About a year later, the king was hunting in an area that he should have known to stay clear of. Cannibals captured him and took them to their village. They tied his hands, stacked some wood, set up a stake and bound him to the stake.

As they came near to set fire to the wood, they noticed that the king was missing a thumb. Being superstitious, they never ate anyone that was less than whole. So untying the king they sent him on his way.

As he returned home, he was reminded of the event that had taken his thumb and felt remorse for his treatment of his friend. He went immediately to the jail to speak with his friend. "You were right," he said, "it was good that my thumb was blown off." And he proceeded to tell the friend all that had just happened. "And so I am very sorry for sending you to jail for so long. It was bad for me to do this."

"No," his friend replied, "this is good!"

"What do you mean, ‘this is good’! How could it be good that I sent my friend to jail for a year?"

"If I had NOT been in jail, I would have been with you."
Wellness Blog
Water Hygiene

Safe water is an essential commodity for prevention of most water and food–borne diseases like diarrhea, typhoid and jaundice. These diseases are 100% preventable. All of them can be lethal if not prevented, diagnosed or treated in time. Transmission of parasitic infections can also occur with contaminated water. Here are a few tips:
  1. Travelers should avoid consuming tap water.
  2. Avoid ice made from tap water.
  3. Avoid any food rinsed in tap water.
  4. Chlorination kills most bacterial and viral pathogens.
  5. Chlorination does not kill Giardia cysts.
  6. Chlorination does not kill amoeba cysts.
  7. Chlorination does not kill Cryptosporidium.
  8. Boiled water is safe.
  9. Treated water is safe.
  10. Bottled water is safe.
  11. Carbonated drinks, wine and drinks made with boiled water are safe.
  12. Freezing does not kill the organisms that cause diarrhea. Ice in drinks is not safe unless it has been made from adequately boiled or filtered water.
  13. Alcohol does not sterilize water or ice. Mixed drinks may still be contaminated.
  14. Hot tea and coffee are the best alternates to boiled water.
  15. Bottled drinks should be requested without ice and should be drunk from the bottle with a straw rather than with a glass.
  16. Boiling water for 3 minutes followed by cooling to room temperature will kill bacterial parasites.
  17. Adding two drops of 5% sodium hydrochloride (bleach) to quarter of water (1 liter) will kill most bacteria in 30 minutes.
  18. Adding 5 drops of tincture of iodine to a quarter of water (1 liter) will kill bacteria within 30 minutes.
Reader Response
Dear Sir emedinews is very informative. Regards: Dr Kaiyra
eMedi Quiz
All of the following regarding aromatase inhibitors are correct except:

1. Unlike tamoxifen, AIs are associated with an increased risk of endometrial cancer.
2. AIs have been shown to reduce bone density, and increase the risk of fractures.
3. Aromatase inhibitors are not indicated in premenopausal women.
4. The musculoskeletal symptoms associated with the AIs are transient.

Yesterday’s Mind Teaser: Which factors may increase your risk of having a stroke?

A. Hypertension and aging.
B. Being female and Caucasian.
C. Being female and African-American.
D. Menopause.
E. B and C.

Answer for yesterday’s Mind Teaser: A. Hypertension and aging.

Correct Answers received from: Tukaram Pagad, Dr K Raju, Dr Poonam Chablani, Dr KV Sarma, Dr Jainendra Upadhyay

Answer for 15th April Mind Teaser: C. Yes, and the headaches are more severe.

Correct Answers receives: Suresh Dange, Dr Avtar Krishan
eMedinewS Humor
Military Medical Clinic

During a visit to a military medical clinic, I was sent to the lab to have blood drawn. The technician there was friendly and mentioned that his mood improved every day because he was due to leave the service in two months. As he applied the tourniquet on my arm, he told me that taking the blood wouldn’t hurt much. Then, noticing my Air Force T–shirt, he asked me what my husband did. When I replied that he was a recruiter, the technician smiled slyly and said, "This might hurt a little more than I thought."
Rabies News (Dr A K Gupta)
If RIG is inadequate to infiltrate extensive wounds, what should be done?

If RIG is inadequate to infiltrate extensive wounds, it should be diluted with normal saline. This is a particular issue in children, whose body weight may be small in relation to the size and number of wounds.
IJCP Book of Medical Records
IJCP’s ejournals
CPR 10
Total CPR since 1st November 2012 – 101090 trained
Video of the Day
Sameer Malik Heart Care Foundation Fund
The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number or by filling the online form.

Madan Singh, SM Heart Care Foundation Fund, Post CAG

Kishan, SM Heart Care Foundation Fund, Post CHD Repair

Deepak, SM Heart Care Foundation Fund, CHD TOF
IMA News
Conference Update - Diabetes India 2015
Diabetic retinopathy: Some people claim to see INTO the future....but will our patients see IN the future

Dr Sehnaz Karadeniz,
Istanbul, Turkey
  • Diabetic retinopathy is a leading cause of preventable blindness in working age population.
  • It is one of the most complex, multifactorial heterogenous disorder.
  • Several factors influence development of an effective screening program such as screening method, population cover, cost and cost effectiveness, guidelines, compliance, quality assurance. We need to make early screening more accessible.
  • Future in screening: Computer aided DR detection, automated identification of DR from color fundus image
  • Laser photocoagulation is effective treatment for PDR. The strongest evidence comes from two RCTs: Diabetic retinopathy study and Early treatment Diabetic retinopathy study.
  • Anti-VEGF treatment was approved by the FDA in 2012.
  • Factors involved in angiogenesis and downstream signaling (PKC, angiopoietins, platelet derived growth factor, Wnt signaling axis) and inflammatory cytokines are other target molecules.
The main challenge is the complex nature of the DR. Several new screening and treatment modalities are in the horizon.

The Correlation between Weight of Mother and the Weight of Offspring

Prof Dr Manjubala Dash, Puducherry

The joy of being a mom is incomparable. Noting that obesity among children is a major public health concern, this study sought to determine the relationship between the weight of mothers and weight of their offspring. Based on the literature review, the correlation between weight of mother and weight of offspring appears to be inconclusive. Objectives: To correlate the mother’s pregnancy weight gain and birth weight of the newborn Hypothesis: There is a significant correlation between mothers weight gain and birth weight of the baby. Methodology: The subjects studied were 80 postnatal mothers in a selected maternity hospital, Puducherry. Data were obtained from the subjects' clinic records and by direct weighing of the baby. The findings were tabulated in terms of means and correlation of the variables: mother's weight and the baby's weight. Findings: The results indicated that there was a significantly positive correlation between the weight of mother and weight of the offspring(r=0.65). Conclusion: Almost 60% of pregnant women are overweight or obese in developing countries. This prevalence of unhealthy weight among mothers-to-be is a serious risk to unborn babies, as it puts their health in later years at risk. A study conducted by Columbia University and Children’s Hospital Boston shows that mom’s weight gain can affect her baby’s health. The researchers tracked more than 500,000 women and over a million babies, finding a significant correlation between mom and baby’s weight. So scientists and public health researchers think pre-programming of a baby’s weight before he’s born could be contributing to the nation’s obesity epidemic.

Electronic medical record: Practical observations

Dr Santosh Malpani, Nanded
  • Meaningful use of EMR can improve quality of care and practice pattern.
  • Inertia of health care system is main obstacle in implementation of EMR.
  • EMR should be based on requirement of care delivery system’s requirement.
  • People who are using EMR can opt for research very easily.
  • Remove inertia and implement EMR to improve revenue generation from practice.
Metabolomics in diabetes research: clarifying molecular mechanisms

Dr GR Sridhar, Visakhapatnam
  • Metabolomics refers to the quantification of endogenous small molecules other than glucose and lipids.
  • Newer technologies such as NMR spectroscopy, gas chromatography mass spectroscopy and liquid chromatography mass spectroscopy allowed separation and measurement of these molecules.
  • A comprehensive analysis of metabolomics provides insights into pathogenesis, and thereby newer treatment targets.
  • Two main classes of chemicals were identified: branched chain amino acid elevation, and subclasses of lipids.
  • Much work has been performed in relation to diabetic nephropathy. The Human Metabolome Database is providing data for analysis into various other aspects of pathogenesis of diabetes and its complications.
Sonal Namaste
Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with soap and water. When bar soap is used, small bars of soap and soap racks that facilitate drainage should be used.
Facts about Tuberculosis (TB)
How is MDR TB diagnosed?
  • MDR TB is diagnosed through a special test called culture and drug susceptibility testing (C & DST), which can be performed by some specialized laboratories.
  • Conventional C & DST (also called solid C & DST) takes 3-4 months to diagnose MDR TB.
  • Newer rapid diagnostics for MDR TB are now available, like liquid C & DST and molecular tests (Line probe assay) which give results much earlier.
Malaria Keypoints
Malaria occurs mainly in the monsoon and post-monsoon periods.
Indian Medical Association drawing up digital code of conduct
New Delhi: The Indian Medical Association is drawing up a digital code of conduct for doctors to help them maintain the profession's code of ethics as a growing number of portals connect them with patients.

The doctors' body says soliciting patients through websites, paying fees to agents that host such portals and doctors boasting of achievements in the social media would be dubbed unethical under this code.

While some portals and digital directories say their goal is to empower patients, the IMA says many are programmed to divert patients from one doctor to another and some charge a fee from doctors - acts that are unethical and illegal.

"Many portals which aggregate doctors' databases and host them seeking to fix appointments with one doctor over the other are violating the law by advertising and soliciting patients, which is not allowed under Medical Council of India's ethics regulations," KK Aggarwal, secretary general of the IMA, told ET. Over a fifth of 6 lakh practising doctors in India are part of some form of online database today, according to industry estimates.

Many times, doctors don't realise that it's not legal, said Aggarwal, citing this as the primary reason for preparing a digital code of conduct. The code will help clarify that ethics that apply in the real world also extend to the virtual world, he said.

When patients search for a doctor, some portals and apps display the address of three of four other doctors with the same specialty in the area, he said. "That is not allowed under MCI ethics regulations, which prohibit doctors from soliciting patients directly or indirectly," said Aggarwal. So is paying a cut to an agent, he said. "Many portals also charge a fee from the doctors for registration and hosting them on their sites and that is illegal as well. At times, they also promise a certain flow of patients. We know this because we also get calls from many of these portals, seeking a cut or commission," Aggarwal adds.

Bragging about medical achievements by posting details of patients on Facebook, Twitter and other social media platforms compromises privacy and would be dubbed unethical. Portals such as Practo and Help-MeDoc told ET they don't charge doctors for registration. Many tech startups in health care say they offer consumers more choice and help them to make informed decisions. Such a code of conduct, if framed, shouldn't stifle innovation and throw the baby out with the bath water, they said.

"Consumers must have easy (and free) access to information about qualified doctors across primary clinics, government and private hospitals as well as private practitioners," said ND Shashank, founder and CEO of Practo, which claims to process 4 million searches on its website and app every month and lists about 1.25 lakh doctors. Practo is keen to work with all stakeholders to help create a framework that ensures every Indian has access to the best healthcare experience, he added.

Clarity from the government on the many grey zones in the virtual world will help as different online models evolve rapidly around doctor-patient relationships, said Suvro Ghosh, founder of HelpMeDoc. He added that the ethical issues that doctors face online are not very different from what they face in the physical world.

The promoter of another healthcare portal, who spoke on condition of anonymity, said this was indicative of a growing chasm between experienced old-timers and young, tech-savvy doctors. Some online platforms map out the locations of doctors, sieving out quacks, and their search engines and databases are used by government agencies, which do not have access to such authentic information, he said.
Antriksh Indian Medical Golf Towers: IMA joins hands with Antriksh Group
IMA has entered into a MoU with Antriksh Group. The group is developing a residential society exclusively for the member doctors of the IMA called ‘Antriksh Indian Medical Golf Towers’, situated at Sector 150, Noida-Greater Noida Expressway, Noida. This residential society and the colony will comply with all health parameters as defined by the IMA making it an environmentally healthy society.

IMA has been able to negotiate the following key items with Antriksh Group for its members:
  • IMA members who wish to book apartment(s) in this society will get a discount of 20% on the basic sales price.
  • Few additional charges such as Lease Rent, Fire Fighting Charges, Club Membership Charges have been completely waived off for the IMA members.
  • In case any member wants to sell off their unit in the open market at any time during the construction, the first transfer fees, which is typically around 2-5% of the cost of the apartment has been completely waived off for the members.
  • If at the end of 1 year, any member feels that the project is not worth investing, they can apply for cancellation and will get 100% refund, without any deduction.
  • Many financial schemes have been created to enable the IMA members to choose the best suitable payment mode for them. One of them is EMI subvention scheme in which the buyer member will be required to pay only 10% of the total cost of the apartment. For next three years, until possession of apartments is offered, the developer will pay pre-EMIs to the financing bank. And after one year of booking, if the IMA member is not satisfied with the value of the investment, they can apply for cancellation and get their money back.
  • Developers will also help the buyer member with loan arrangement.
  • The society once in frame will co-own the management of the Club House called “IMA House” and the Golf Club.
  • Relatives of IMA members will also be entitled to book flats in this scheme.
It is expected that once 200 member doctors buy apartments in this project, the market cost of the apartments will increase by minimum around Rs 1000 per sq ft in one year and by a minimum Rs 2000 per sq ft in 2 years’ time frame. This will yield to a buyer who books under the subvention scheme, a profit of 200% and 400% over a period of 1 years and 2 years respectively. Buyers can keep that parameter as a benchmark of gauging the return on their investment.

The apartment buying agreement of the IMA member will be directly with the developer and IMA will not be party to it. IMA has only negotiated special terms for the members.

Members who wish to enquire about the project, visit project site or book may contact the special helpdesk created by Antriksh.

Contact details

Phone helpline: 92124 11999
Email helpline: antriksh.ima@gmail.com
Project website: www.antrikshimagolftowers.in
Antriksh Group website: www.antrikshgroup.com
IMA website: www.ima-india.org

Snapshot of key features of the project (as per project Brochure)
  • Lowest density sector in Delhi NCR leading to limited number of units and wide open areas
  • Project in the centre of a 9 Hole signature Golf Course
  • 3BHK and 4 BHK apartments with super area – 2025 sq ft, 2425 sq ft, 2900 sq ft and 3475 sq ft
  • Sector located at the junction of 3 major expressways
  • Certified Green Building Concept
  • Ultramodern club house with Swimming Pool
  • Maximum sports facility including Cricket Academy
  • Sr Sec School, Nursing Home, temple, Local market all within the township boundaries
  • 24x7 electricity and potable water supply
  • 3 tier security system with CCTV monitoring in centralized Hi-tech control room.
Some of the key features of ‘Health Friendly Homes’ concept created by IMA are as follows:
  • Air and Noise Pollution Control
  • Water Softening Plant
  • Mobile Tower Radiation Free Zone
  • Rain Water Harvesting
  • Eco friendly Garbage Disposal
  • Nursing Home/Healthcare Centre
  • First Aid Kits and First Aid Centres
  • 24×7 Ambulance Facility
  • Potable Water Supply
Quote of the Day
Our greatest weakness lies in giving up. The most certain way to succeed is always to try just one more time. Thomas A. Edison
IMA in Social Media
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IMA Videos
News on Maps
Patients with family history of high cholesterol should be screened early
Premature heart disease is when heart disease occurs before the age of 55 years in men or before the age of 65 years in women. The prevalence of dyslipidemia in these patients is high, in the range of 75-85%, said Padma Shri Awardee Dr A Marthanda Pillai National President Indian Medical Association and Padma Shri, Dr B C Roy & DST National Science Communication Awardee, Dr K K Aggarwal, President Heart Care Foundation of India and Honorary Secretary General Indian Medical Association.

Dyslipidemia is high levels of cholesterol and/or triglycerides in the blood. About 54% of all patients with premature heart disease and 70% of those with a lipid abnormality have a familial disorder. Hence, it is recommended that the first-degree relatives of patients who have had a heart attack, especially if premature, should be screened for lipid abnormalities.

First-degree relatives of a person include brothers, sisters, father, mother or children; second-degree relatives are aunts, uncles, grandparents, grandchildren, nieces, or nephews and third-degree relatives refer to first cousins, or siblings of grandparents.

Screening should begin with a routine lipid profile and if the results of this are normal, then further testing should be done for lipoprotein (a) and apolipoproteins B and A-I. About 25% patients with premature heart disease and a normal standard lipid profile may have abnormal Lp(a) or apo B profile. High apo B levels and reduced apo A-I levels are associated with increased risk of heart disease. Similarly, a high Lp(a) level increases the risk of developing heart disease.

Familial hypercholesterolemia (FH) is a genetic disorder, which runs in families and is characterized by high cholesterol levels, in particular, very high levels of LDL or the bad cholesterol and premature heart disease. Patients with FH are at an increased risk of developing premature heart disease at an earlier age of 30 to 40 years.

Heterozygous FH is a common genetic disorder, occurring in 1:500 people in most countries. Homozygous FH is much rarer, occurring in 1 in a million births. Heterozygous FH is normally treated with drugs. Homozygous FH often does not respond to medical therapy and may require apheresis or liver transplant.

Heterozygous FH is when the FH gene is inherited only from one parent. If both parents have FH and the FH gene is inherited from both of them, this is homozygous FH.

Universal screening at the age of 16 years should be done to detect familial high cholesterol levels. In patients with heterozygous FH, the cholesterol levels are between 350 to 500 mg/dL, and in homozygous, the levels are between 700 to 1,200 mg/dL.
World Medical Association Ethics Committee Advisors
In the 200th World Medical Association Council meeting, held at Norway, WMA appointed Dr Vinay Aggarwal Past President Indian Medical Association (IMA) and Dr K K Aggarwal Honorary Secretary General IMA as advisors to WMA Ethics Committee.

Dr Vinay Aggarwal is a member of Ethics Committee of Medical Council of India (MCI) and Vice President of Delhi Medical Council (DMC). Dr K K Aggarwal has served as Member Ethics Committee MCI and is Chairman Ethics Committee of Delhi Medical Council.

The Ethics Committee of WMA meets twice a year and discuss various ethical issues concerning the society.

Dr Ajay Kumar Past President IMA is already a member of Ethics Committee Council of WMA.